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Complicating the development of SBIRT protocols for the treatment of alcohol use problems is the limited evidence of its efficacy. Only two randomized controlled trials of SBIRT for alcohol use problems have been completed.^{283, 284} Although these studies both showed improvements in alcohol outcomes, both studies showed no difference in the number of risky drinking days in the group receiving brief motivational feedback plus referral compared to the group receiving motivational feedback plus usual care. ²⁸⁴ Several systematic reviews of the evidence for SBIRT report inconclusive results of brief interventions for risky drinking by non-clinicians.^{285 – 287}

However, these two methods, along with the other SBIRT protocols, still require empirical investigation to understand if they are effective, if cost-effective, and if they have the potential to be part of routine clinical practice to help improve patient care. ^{290, 293}

Secondary conditions. Chronic infectious diseases and/or ectopic pregnancy are the most common causes of abdominal pain. Intestinal obstruction can be caused by adhesions from previous abdominal surgery or rarely by tumors (such as liposarcoma or mesenteric fibromas). With dense adhesions, diagnostic and therapeutic laparoscopy and laparotomy are performed to minimize the risk of abdominal-pelvic sepsis. In general, preoperative imaging is limited; however, however, a CT scan may be helpful to assess for a possible cause of abdominal-pelvic pain, including narrowing of the pelvic outlet or abdominal pregnancy. The incidence of ectopic pregnancy is highest in the first trimester. Its presentation is variable and nonspecific, ranging from mild pain and vaginal bleeding to severe pelvic pain, heavy vaginal bleeding, and shock. Abdominal and pelvic pain from ectopic pregnancy can mimic other common causes of pelvic pain, and ectopic pregnancy should be considered in a patient with abdominal pain and no other pain source. On imaging, ectopic pregnancy appears as an intraconal endometrioma with a heterogeneous CT density. Although other causes of a large, intraperitoneal, echogenic mass in the adnexa have been reported, an ectopic pregnancy is the most common potential etiology. Intrauterine device migration is another cause of abdominal-pelvic pain in young, nulliparous women. The device migrates into the abdomen and contacts the bladder, provoking irritation, abdominal pain, and dysuria in the setting of tamponade or mechanical obstruction. Usually, CT and ultrasound imaging can identify the migrated IUD, and urogynecologic management is the primary treatment for these patients. Diagnosis of salmonella infection (especially the more virulent strains) is difficult and the onset is often insidious, presenting as nonspecific abdominal pain. Owing to the noninvasive nature of the organism, a definite diagnosis can be made by stool cultures in addition to routine bacterial cultures and serologic testing for antistreptolysin O titer. Resolution is gradual and can take weeks, with the patient sometimes requiring oral antibiotic therapy for a prolonged period of time. Antibiotics are used to control the infection, but a definitive diagnosis of salmonella is usually made only by isolating the organism from the tissues involved. Antibiotic therapy should be given for at least 4-6 weeks and may be continued for a total of 1-2 months after the patient is clinically cured. Diet modification is an important element of the therapy for active salmonella infection. Patients infected with salmonella are often advised to avoid raw eggs and undercooked poultry, but these kinds of interventions are of limited value for patients infected with known strains of salmonella. In one case, a patient with salmonella infection developed a fever, a history of recent infection with salmonella, and a large, tender, painless, and deep subcutaneous abscess at the palmar aspect of the right second finger. This is a rare form of salmonella infection that usually occurs in neonates and affects one finger. The abscess was drained, and a diagnosis of Salmonella paratyphi A was made based on the Gram stain of the pus and the subsequent recovery of a Gram-negative organism in the stool. As with other bacterial infections, the primary treatment for salmonella infection is usually with a fluoroquinolone antibiotic; however, in patients with a history of bacteremia or hepatic insufficiency, ciprofloxacin should be avoided as an alternative.

Access to health care services can be hindered due to drug use and criminal activities, which has been proposed as one of the driving forces for individuals who use illicit substances to dispose of their drugs in and around the home and to conceal from health care providers that they use drugs. These concerns have the potential to undermine the continuum of medical and dental care for PWUD. In the United States, almost half of all drug overdoses occur within the community; this may explain why direct access to medical and dental care is more difficult for this group of people. Furthermore, in some areas, emergency medical response teams are often formed specifically to address the issues of those who use drugs in emergency situations; these specialists are well trained in the assessment and treatment of these patients who have “drug-contaminated” patients in the emergency room.
In response to high rates of dental disease among people who use drugs, health care professionals have developed several interventions to alleviate such problems. For example, health care professionalssuggest that PWUD exhibit a lower willingness to change their behaviors for a period of time, which is an important factor for dental hygiene recommendations. Such interventions may include the provision of a prescription for a basic dental care kit, 70 a preventive and screening visit 71 , dental checkups with motivational interviewing (MI) approaches, which involve being empathetic, collaborative, and goal oriented during the interaction with patients who use drugs [ 72 ], and regular visits to the dental office 73 .
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